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Saturday, April 23, 2011

The Valley of the Shadow

I never expected residency to be a cakewalk. I knew it would be hard, especially as a woman. Growing up in the deep South, I understood the concept of the "good ole boys' club." Believe me, it's still alive and well.

In the dark ages, when I started residency, there was no 80-hour work week. We were expected to stay until the work was done, which admittedly prepared me well for the real world. As a new intern, I thought that if I just put my head down, did all the work, and never complained, that everything would be fine. More than one woman had already graduated from my training program, so I figured the ground had been broken. I was optimistic as I rolled up my sleeves and dug in.

In my PGY-2 year, my fellow residents and I calculated that we were working about 120 hours a week on average, and that came to about 33 cents/hour. We tried not to think of that too often!

In my PGY-3 year, I became pregnant (amazingly, nature cooperated with our plans). I spent my third trimester as the junior neurotrauma resident at the second busiest trauma center in the country. It was known to be the hardest rotation in the program. I caught the expected grief from my (male) fellow residents, but I never missed a day of duties or call. I worked up to 38 weeks as planned. I took maternity leave (after a C-section) during my neurology elective, during which one did not take neurosurgery call; my fellow residents were therefore inconvenienced not one whit.

Things went fairly smoothly after my return 6 wks postpartum, to my mind. Fast forward through lots of backbreaking work to PGY-6, my last year. I had just completed a complex spine fellowship and was looking forward to a happy ending in about 6 more months. It was fun teaching the junior residents basic neurosurgical skills. I had a happy, healthy 3-year-old son and a loving husband. I could see the light at the end of the tunnel.

One afternoon, I went to one of the ICU's to deliver the articles each resident had to present at journal club the next morning. I approached a group of about 5 younger residents and greeted them as usual. One of our attendings was doing paperwork nearby. I held out an article to a PGY-5 I'd worked with for years.

He glared at me and said flatly, "I'm not taking this. I have plans this evening, and I don't have time to prepare. You'll have to do it!"

I stared at him, taken aback, as he stood there oozing belligerence. Then the other residents chimed in. In the middle of the busy ICU, they took me apart, my colleagues who I'd worked beside, covered for, praised and supported.

"You are so lazy." "You have a terrible attitude." "You never seem to be there to help with anything." "We're tired of working with someone so lazy." "This is all your fault."

"Lazy." "Lazy." "Lazy." It echoed, etched itself in burning letters in the air. I don't remember much else of what they said; mostly I remember the looks on their faces, the silence of the one resident I thought I had known the best.

I hadn't known them at all. And they didn't know me at all, these men who all had stay-at-home wives who took care of everything for them, had their children, made them dinner. They could carelessly condemn me without ever having been to my home, met my family, asked me anything about my life. They could never know the phone calls I'd taken for them, the things I'd done with patients in the afternoon so the call guy wouldn't be bothered. So much they didn't ever know, and didn't really care to know. So much hard work I'd done that had made no difference.

I remember leaving the ICU, articles in hand, without seeing anything around me. I paused in the parking lot just outside the door; turning, I saw the attending just behind me, and I knew he'd seen the whole thing. I asked, "Dr. X, could I talk to you for just a minute?"

To my complete astonishment and dismay, he stammered, "Have to be at, ah, a meeting, ah..." and actually *ran* to his car, leaving me standing there. So much for expecting any support from on high.

I went straight home and sobbed on the sofa for an hour, unable even to tell my husband what was wrong. Then, as a good neurosurgical resident should do, I prepared all the articles myself. I walked into journal club at 6:00 am and presented them all. I explained to the chairman that it was all my fault they didn't get distributed. And then I went to the OR.

For the next 6 months, those residents made my life miserable. Every day, I dreaded walking into the hospital. I dreamed about the word "lazy." I never, never asked for help, because you don't do that in neurosurgery. I blamed myself, because that's what you do as a surgical resident, even though I knew better. But I faced them all down, every day. It was the hardest thing I had ever done.

To this day, I still don't know why they did this. I'll probably never know, since I avoid the residency reunions held every year at the national meeting.

I was so relieved to get in the moving van at the end. Shortly before we left, the chairman held the annual dinner honoring graduating residents (there were two of us). My fellow residents had prepared the slide show, including a section spoofing the "Priceless!" commercials on the air at the time. It intimated that getting gcs15 to come in to help with a case was "priceless." My husband and my co-senior resident's wife got the same "spouse's gift" - a dried flower arrangement.

My neurosurgical training was excellent, and it has stood me in good stead over the 10 years since finishing. I have enormous respect and gratitude for many of my professors. I can say that I am a good surgeon with confidence. I love my profession, and I still can't imagine doing anything else.

What I have come to realize, however, is the destructive effect residency had on me. I'm sure I'm not the only one. I love neurosurgery, but I hate its culture. The primary tenets are: don't ever complain and always accept responsibility, even if it's not your fault. Most importantly, don't EVER, EVER, ask for help. If you do, it's a sign of weakness. If you do, you are not worthy of Neurosurgery. Call me if you need me... but don't call me, because you will be vilified. This is true in training, and it's just as true in practice. And if you don't fit the neurosurgical stereotype, you don't "belong."

I have never really gotten through the Valley of the Shadow. I have worked harder and longer than I should have worked to prove to everyone, especially myself, that I am not "lazy" after all, even though I know I never was. I swore that no one would ever speak to me again like those residents did, and I found myself unleashing a tirade on an anesthesiologist once because of that. He started off, "The problem with you is..." and I just snapped. It was visceral. The shadows still darken the valley.

Running a neurosurgical practice is hard, complicated work, but I have made it harder than it should be. Because of this, my family has suffered. I have tried very hard to strike a balance, but it has not been enough to avoid inevitable crisis. Wisdom is only gained through hard experience; I hope I have enough now to finally get past the demons. With this, much of the fault is truly mine. I should have forced myself to exorcise them long ago; I underestimated their menace.

To those who would tread the path of surgical subspecialty, I say it can be done. I know what I must do to correct my mistakes and make things better for my family. You will make your own mistakes and face your own Apollyon, but you too can overcome. One day, the culture will change. We must make it so.

"Now morning being come, he looked back, not out of desire to return, but to see, by the light of the day, what hazards he had gone through in the dark. So he saw more perfectly the ditch that was on the one hand, and the mire that was on the other; also how narrow the way was which led betwixt them both; also now he saw the hobgoblins, and satyrs, and dragons of the pit, but all afar off, (for after break of day, they came not nigh;) yet they were discovered to him, according to that which is written, 'He discovereth deep things out of darkness, and bringeth out to light the shadow...' " - Pilgrim's Progress, by John Bunyan

23 comments:

Reminds me of the lazy male resident who begrudged me, quite openly, for taking two maternity leaves during residency. Never mind that I had NO VACATION for three years because of that. Oh and yes, caring for and nursing a newborn all night, however taxing, is akin to a beach trip to Hawaii, right?

You are truly amazing. When can we let go of our own egos and realize that the criticisms we internalize from others are really our own demons? May you find your own peace between the ditch and the mire - I'm working on that myself, and believe me, the work is quite rewarding. Good luck to you on your path.

thank you for sharing this. i will be soon choosing on a specialty and i find it hard to rule out surgery over IM. most surgeons i've assisted have complimented me and are encouraging of me, but suggest "plastics" for me as "i'm a girl" and it's "hard being a woman" in surgery.so i've sought online other women's stories of their surgical residency but i find a lot of them gloss over the experience or dismiss their struggles. i am glad that you are very honest with your difficulties besides the surgeries as the surgical culture is something that makes me hesitant. i never liked surgery because of that, but when i actually started rotating and becoming hands-on, i got to appreciate it a lot more. many things to think about in these coming months. thanks

I think this story would hit home for anybody who's been in residency (even the easier ones :). There are things that happened to me during my intern year that I can't even bear to talk about still. And my maternity leave was always a huge source of guilt for me.

What sucks is that you can't entirely blame the residents in some of these situations. When they're stretched to the limits of what they can tolerate, any little nothing becomes a source of huge grief. For that reason, I try to forgive the intern who yelled at me for missing a few hours of call while I was pregnant and bleeding. It's the whole process that needs to be changed.... it turns residents into heartless monsters.

Then again, there were similar issues in my PM&R residency, when nobody was working all that hard. One resident stirred up huge amounts of drama (which resulted in tears on my part when he bad mouthed me to other residents) to get out of working Friday afternoons on a rotation that was already fairly easy and had minimal call. At least in that case, it cost him chief residency. Small consolation though, because he got the fellowship he wanted anyway.

Not a resident but I know this feeling a bit too. Switched shifts at work and had a guy yell at me for being lazy because I expected him to do his job instead of doing it for him while he sat and screwed around on the internet. Another time there was something I wasn't trained on because I was just filling in so I said that I hadn't been trained because I was covering but if he showed me what to do I'd do whatever I could to help. He grumbled the whole rest of the night and refused my offers to help then I got called in to talk to management the next day because he'd told them that I'd said I didn't think I should have to help because I was covering. Fortunately the supervisor knew me well enough to know better and he had a history of attitude problems, but it still sucked and hurt my performance review at the end of the year. I sometimes wonder if I want to put myself through that crap by going to residency...

I think sometimes the criticism we unleash on others is a reflection of what we are afraid of in ourselves. Meaning, those other residents were so afraid of appearing lazy, that they accused someone else of it instead. Whether consciously or not, if you make enough noise about someone else's "fault" (true or not), then maybe no one will notice that about yourself.

I am sure you were an excellent resident and worked extraordinarily hard. I just find it sad that it was so trying for you. I am not a surgeon (I practice Med-Peds), but I would like to hope that there are surgical programs out there that are not so malignant; where I trained, the surgeons (both men and women) seemed content.

I enjoy reading your posts. I am nearly finished with general surgery residency and had one child during. I know that surgery has gotten "easier" over the past few years, but I think it can still be rough. What you describe in this article, I have certainly felt before. I see myself now and can clearly identify how 5years of surgical training have changed me. Some of the changes are good though. I hope it does "get better" after fellowship as everyone says. But I completely agree that the men with stay at home wives cannot even come close to imagining working as much as we do and then go home and start our second job...and still study to do well on inservice exams, and write papers, and make birthday cakes, and do laundry too.Even with a supportive husband, I want to do as much care for my son as I can. So time to take care of myself is sacrificed. One day in the OR one of the RNs was saying how she felt bad for me because I work late so often and dont see my son, and my attending rudely said that I chose this. In choosing to do one thing, you choose not to do another. I was so shocked to hear him say that. Like I didnt want to be home with my family. It hurts. Of course he is on his second marriage and his wife stays home with his kids...I feel that it is hard to find role models, but maybe one day I will be a role model for someone else.

You'll find sucky people in every field. It's part of having a job. Medicine is not special in this regard, unfortunately. This just underscores the importance of finding not only what you love to do, but also a group of people you enjoy working with.

I always enjoy your honest posts. I still remember events during residency I would rather forget. When you can't pee/eat/sleep when you need to, it can make you momentarily inhumane. I remember feeling annoyed at the medical students who took off to eat lunch when I was running around admitting patients as a senior resident. I knew I wouldn't be able to eat for the next 3-4 hours. I consider myself a nice person, but even I had that brief moment of feeling, "if I don't get to eat, they don't get to eat" mentality. Residency just sucks, in general. I don't think I would survive Neurosurg residency.

Thank you for this honest and open post. I'm starting residency in a couple months and I know I will have to face a lot of challenges along the way. I would like to have a baby at some point in residency and I know it will be so difficult - I hope that my fellow residents are supportive.

Thank you gcs15 for sharing some of your struggles here, this needs to be heard and this culture needs to change. I wonder if your co-residents ever got to know any of their patients. I feel sad to read what you've been through. I also am worried that they won't ask for help when they need it, and make others feel like they cannot. Please keep writing through it all, we are here for you as a MiM community and you can ask US for help.

I had an experience like this (though not nearly as extreme) when I started in ICU as a 22-year-old new graduate nurse. The older nurses assumed because I was young, I was stupid and easily manipulated. I responded the way you did: worked even harder, tried to never ask for help, and NEVER stood up to them.

Many years later, the more I reflect, the more I realize that I was not at all stupid, and should have been more proud of the work I was doing.

Now that I will start internship soon, I feel like I have another chance to be the genuine person I want to be, answering truthfully when confronted with uncomfortable information...even when the truth I need to tell is that I AM a good worker, and deserving of respect.

I love the phrase "don't demand respect, command it", and try my best to live by it. But commanding respect, I've realized, sometimes means asking for it.

That is an upsetting story and I can imagine why you are finding yourself now trying to come to terms with its affects, even with all you've accomplished. But big picture - you rock! Perhaps these young men could excuse each other for not being 100 percent perfect, but because you were a woman and a mother, you were vulnerable to their judgment, an "easy" target. But it just makes you twice as kick a-- in my mind!

gcs15~ Oh, your story cuts right to my heart, because it feels like my own (except I know I didn't work nearly as hard as you did!!) I, too, was blindsided by utter contempt from fellow residents whom I thought were my friends when I dared develop a pregnancy complication, thus burdening them with more call. (Got accused of doing it ON PURPOSE! As IF!) And I was always a hard worker, throughout the entire residency. Went above and beyond all the time...didn't matter, all they remembered was that I took "time off" during my pregnancy. I didn't even go to the residency banquet that year because I was so devastated. Assholes, all of them. Good for you for facing them all down, and ultimately, living well is the best revenge.

GCS15I too did my general surgery residency before reduced hours. I am amazed that you were able to have a child during your residency. Amazed. Those brats who called you lazy have NO IDEA what you were going through. I was always amazed at the male residents who could have children, but do realize their wives did all the work.

There is definitely an 'old boys' network at play in surgery. Hence the staunch support of Greenfield (of Greenfield filter fame) in his op ed piece that basically promotes unprotected sex as a mood enhancer for women.

In response to Anonymous at 2:04 pm. I suspect there are many places where reduced hours don't exist in private. I havent' been able to understand how any surgical specialty (except for things like opthomology) can expect to exist in private practice without having some of the long hours in training.

Giz, men just don't seem to get the concept of maternity leave, do they? Thanks for the encouragement.

Maia: I agree, it is a lot to think about. There is nothing easy about being a surgeon. You have to decide if you love the surgery and the patients enough to make it worth while fighting battles like these. It was worth it to me, but it wouldn't be to everyone. Good luck to you!! :-)

Fizzy: I couldn't talk about this for years, it was too painful. It's been therapeutic to finally write it down and put it out there. I can't forgive them as easily as you, though. They kept the torture going relentlessly for 6 months, and to me that's unforgivable.

Anon #1: I feel you, and I'm sorry you had to go through that.

Anon #2: You may well be right about the concept of criticism. Maybe this played a role I didn't understand at the time. Thanks for your insight.

Anon #3: Please do as I say, not as I do - take time to take care of yourself! Otherwise you'll be like me in 10 years - overweight, overstressed, and isolated. It's easier to avoid that at your stage than to fix it at mine, as I am trying to do. That said, surgical training changed me in a lot of good ways, too. We have to learn to make the best of our experiences, good and bad. It's hard.

OMDG: You are so right! I wish I liked neurosurgeons as much as I like neurosurgery.

Anon 4:11: I've had that feeling towards students and OR staff too. Hard to help it when you're starving!

Dr. Army Wife: Good luck to you!

T: You get that by writing this, I was indirectly asking for support as well as trying to inform and reflect. This is a difficult time for me. Sometimes you just need to know that somebody out there cares - thanks, just thanks.

scrubmama: Take your chance with both hands! Never underestimate your worthiness. I too love this phrase.

Anon 9:53: Thanks!!

dr whoo?: I hate that we had to go through misery like this - it's not fair. I wish I'd known you at the time so we could commiserate. It's a very lonely experience.

Kellie: Thanks! And I can't print what I have to say to Greenfield... :-)

Anon 2:04: I am not surprised.

Kellie: I agree that the long hours were good training. I would not want to come out into practice thinking I can punch a timeclock; what an unpleasant awakening that would be! I didn't object to the long hours or the hard work - I think that was good for me in some ways. I mentioned it to set the stage for the rest of the story.

Hats off to you, GCS. I'm an MD/PhD student nearing the end of my clerkships, and have had my own painful experiences already as a third year and mom. I really admire you and have enjoyed your posts for many months now. Good for you for surviving and doing the incredibly important work of a neurosurgeon and mother.

I am a mother in medicine and neurosurgery patient. I discovered I had a large brain tumor during my fellowship a few weeks after my 2nd child was born. I am deeply grateful to my NSG team. The woman neurosurgeon was especially involved. She called me at home to tell me everything about complications, and what to expect. Tears were streaming down my face as I was listening, but I am glad she prepared me mentally. She called me the night prior to tell me what approach they are going to take tomorrow. She told me she was shocked I was seeing my clinic patients at almost 6 pm the evening before my surgery. The fact that someone was being human, was so special in my situation. Like you I had experienced coldness of my peers at the time. When I returned to traning 3 weeks after surgery when most take 2 months off, fellowship director informed me fellows are upset they had to share my evening call (on the phone only) for my 3 weeks maternity first then neurosurgery. It ended up being one call per 6 fellows. I was told I am expected to pay it back. When I announced to the fellows I am taking the calls back, I still had visibile paralysis. I could not talk very well either. These people were mostly single, or had home staying wifes with grown kids, and mostly were research fellows with no in house call. Here I was a criple with a newborn and 2 yo at home. Something inside me was broken when I saw their aloof faces, and their hasty manner to throw that call day at me, and almost disgust at my disability. None of them ever asked me how I felt after my surgery. I am blessed I have better people around me now. I am blessed to have had skillful people like you curing me. I beleive I am a better person than any of my ex-fellows (taken together). Do beleive in your own good.Be proud of yourself.

Thanks for writing about all of this so honestly. If nobody speaks up about how it really is, things won't change...and the people coming up behind you will be totally blindsided when these things happen to them (and from the sound of the comments, it is entirely too common still).

Thank you for writing this. I am an anaesthesia resident who is a new mother and see a lot of what you describe. It was terrible what happened to you, and having discovered some of the challenges, I really am thankful that you voiced this. I am often surprised within residencies how different the boy vs girl talk can be - the false bravado and machosism vs women's desire to support, nurture and create community. Honestly, the derision I hear from people who don't understand what it takes to parent or manage home equally (e.g. men who have stay-at-home-wives, have all food made, and then who pull the occasional superdaddy hour...who then criticize MiM in very different circumstances, "you do what you have to do,(look at me I am superdaddy and surgeon), call me but don't call me, no real support, it's your choice that you are in a surgical type specialty and don't be lazy." or the backtalk heard when they think they are not being observed - it is a club that is infuriating at times.

They do not understand as they have not walked in the other person's shoes. They are missing out on their own family and home. And the worst of it is that they do not know what they are missing by not being involved. It is women with careers and families that are exposing a new generation of men to the joys of true parenthood not the superdaddy kind.

If women had set up medicine, it would not be this machosistic culture - it would have been a more supportive nurturing one, with as much guaranteed breaks, reasonable hours, support and covering for each other - the types of things that nursing values. Don't get me wrong, I love medicine, would not trade it, am very enthralled by what I do and surgically related fields. And yes we make choices - but I disagree with notions that accepting things as they are is the way to go - on one hand, there is choosing the right time to push for change so as not to have political suicide, but on the other, we cannot placidly accept things as is - which is why I am so thankful you have written this. We need MiMs and we need them to speak out and be heard. We also need women who have broken through the glass ceiling like yourself to shine the light on these areas for change. And true change needs critical mass. People are constantly saying this surgical practice is this way i.e. crazy amount of call for some reason, but in truth, there are other work schedule alternatives if everyone buys in. But it takes critical mass to explore these alternative work scheduling models etc. Enough personnel to make call reasonable. Gawande writes that we have a cowboy culture in surgery but we need to move towards pit crews - mothers everywhere have adopted this type of approach. But it is a rare father in medicine who is that involved at home to understand. And in defense, I also meet the occasional female physician with total stay-at-home partner who does everything (i.e. complete role reversal, and she doesn't necessarily appreciate it either.) I am hopeful that as Equally Shared parenting, if it can work as the Vachons describe it becomes the norm ( even if not split 50-50%) it will be certainly useful for fostering empathy and understanding. Cultures need to change and "time itself is neutral" (King) and won't change it, it is people that change things- the first step is exposure and it is the brave step you have made for us. Thank you.

As Martin Luther King Jr said- Injustice anywhere is a threat to justice everywhere.

Mothers in Medicine is a group blog by physician-mothers, writing about the unique challenges and joys of tending to two distinct patient populations, both of whom can be quite demanding. We are on call every. single. day.

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